Provider Forms

• Precert Fax Form
• Pharmacy Review Form

Definition of Urgent Care

Urgent Care: A request for medical care or services where application of the time frame for making routine or non-life-threatening care determinations

1. Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on the prudent layperson’s judgement or
2. Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state, or
3. In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request for example immediate threat to life or limb, or significant pain and/or suffering.